JBMR

ORIGINAL ARTICLE

Recent Trends in Hip Fracture Rates by Race/Ethnicity

Among Older US Adults
Nicole C Wright , 1 Kenneth G Saag , 2 Jeffrey R Curtis , 2 Wilson K Smith , 1 Meredith L Kilgore , 3
Michael A Morrisey , 3 Huifeng Yun , 1 Jie Zhang , 1 and Elizabeth S Delzell1
1

Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA

Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
3
Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL, USA
2

ABSTRACT
Hip fracture incidence has declined among whites in the United States since 1995, but data on recent trends in racial and ethnic
minorities are limited. The goal of this analysis was to investigate hip fracture incidence trends in racial/ethnic subgroups of older
Medicare beneficiaries. We conducted a cohort study to determine annual hip fracture incidence rates from 2000 through 2009 using the
Medicare national random 5% sample. Beneficiaries were eligible if they were
65 years of age and had 90 days of consecutive full feefor-service Medicare coverage with no hip fracture claims. Race/ethnicity was self-reported. The incidence of hip fracture was identified
using hospital diagnosis codes or outpatient diagnosis codes paired with fracture repair procedure codes. We computed agestandardized race/ethnicity-specific incidence rates and assessed trends in the rates over time using linear regression. On average,
821,475 women and 632,162 men were included in the analysis each year. Beneficiaries were predominantly white (88%), with African,
Hispanic, and Asian Americans making up 8%, 1.5%, and 1.5% of the population, respectively. We identified 102,849, 4,119, 813, and
1,294 hip fractures in white, black, Asian, and Hispanic beneficiaries over the 10 years. A significant decreasing trend (p < 0.05) in hip
fracture incidence from 2000-2001 to 2008-2009 was present in white women and men. Black and Asian beneficiaries experienced
nonsignificant declines. Irrespective of gender, the largest rate of decline was seen in beneficiaries
75 years of age. The overall and agespecific rates of Hispanic women or men changed minimally over time. Hip fracture incidence rates continued to decline in recent years
among white Medicare beneficiaries. Further research is needed to understand mechanisms responsible for declining rates in some and
not others, as hip fractures continue to be a major problem among the elderly. 2012 American Society for Bone and Mineral Research.
KEY WORDS: HIP FRACTURES; RACE/ETHNICITY; EPIDEMIOLOGY; MEDICARE; SECULAR TRENDS

Introduction

ith increasing prevalence with age, osteoporosis and

related fractures constitute one of the most significant
public health concerns for aging populations.(1,2) Recently,
Cooper and colleagues(3) reviewed published data on secular
trends in the incidence of hip and other osteoporotic fractures
worldwide. In the United States, the incidence of hip fractures,
the most devastating fracture associated with osteoporosis, has
declined since 1995, with a 24.5% decrease in women and 19.2%
decrease in men of the age-adjusted hip fracture incidence rate
between 1995 and 2005.(4) Similarly, Leslie and colleagues(5)
reported an annual 2.4% decrease in women and an annual
2.0% decrease in men each year between 1996 and 2005 in
Canada.
Bone density and fracture rates,(6,7) as well as fracture
outcomes such as rehabilitation rates and mortality, vary by

race/ethnicity.(811) The comparability of the fracture trends

observed by Brauer and colleagues(4) to other racial and ethnic
groups has been called to question as 95% of the population in
their study was white. Smaller, regional studies have suggested
that the decreasing trend is either smaller or nonexistent in other
racial and ethnic groups. For example, an analysis of hospitalization data from New York State indicated that the hip fracture rate
in African American and Hispanic women declined between
1995 and 2005 only slightly compared to a more appreciable
decline in white women.(12) Similarly, a study of California
hospitalization data noted a significant decrease from 1983 to
2000 in the annual hip fracture rate in non-Hispanic white
women, no significant decrease in black women, and a
significant 2.5% increase in annual hip fracture rates among
Hispanic women.(13)
A nationwide examination of racial and ethnic differences in
fracture incidence has not been reported since 1994.(14) Because

Received in original form February 23, 2012; revised form April 25, 2012; accepted May 31, 2012. Published online June 12, 2012.
Address correspondence to: Nicole C Wright, PhD, MPH, 1665 University Blvd, RPHB 523C, Birmingham, AL 35294, USA. E-mail: ncwright@uab.edu
Journal of Bone and Mineral Research, Vol. 27, No. 11, November 2012, pp 23252332
DOI: 10.1002/jbmr.1684
2012 American Society for Bone and Mineral Research

2325

an increasing proportion of US older adults are comprised of

racial and ethnic minorities and because fracture trends may vary
by race and ethnicity, we examined recent trends in hip fracture
incidence by race and ethnicity among Medicare beneficiaries,
the most representative sample of older adults in the United
States.

Subjects and Methods

Study population
We created annual cohorts for each year between 2000 and 2009
using the enhanced national 5% random sample of Medicare
beneficiaries, obtained from the Center for Medicare and
Medicaid Services (CMS) Chronic Conditions Data Warehouse.(15)
The data included claims for all Medicare-covered services with
relevant International Classification of Diseases, Ninth Revision
(ICD-9), diagnosis and procedure codes and Healthcare Common
Procedure Coding System (HCPCS) codes used to identify
surgical, diagnostic, or other medical procedures.
We used self-reported race/ethnicity, populated in the
Medicare enrollment database based on Social Security
Administration records.(16) Categories included: white, black,
Hispanic, Asian or Pacific Islander, American Indian or Alaskan
Native, or unknown. Due to the small number of beneficiaries
and the inability to identify a specific race/ethnic group, we did
not examine trends among American Indians/Alaskan Natives
and beneficiaries with unknown race/ethnicity. The study was
approved by the Institutional Review board at the University of
Alabama at Birmingham and by CMS.

Eligibility
Person-days were the units of observation for this analysis. A day
was considered eligible when the beneficiary was in the 5%
sample, at least 65 years of age, and lived in the 50 states or
Washington, DC; and when the day was preceded by at least
90 days of consecutive traditional fee-for-service Medicare Part A
and B coverage with no hip fracture claims. The consecutive
90-day coverage requirement could span 2 years. The purpose of
the latter requirement was to ensure the identification of an
incident, rather than prevalent, fracture among those with a
previous hip fracture. To ensure completeness of claims to
ascertain hip fractures, we excluded person-time when a
beneficiary was enrolled in a Medicare Advantage plan operated
by independent healthcare maintenance organizations (HMOs).
Assuming all of the above criteria were met, a beneficiary could
experience more than one hip fracture event in a given year.

Identification of hip fractures

We used ICD-9 diagnosis codes 820.0, 820.2, and 820.8 to identify
incident closed hip fractures. We excluded open hip fractures
(820.1, 820.3, and 820.9) (0.24% of all hip fractures) due to their
likely relationship to severe trauma rather than osteoporosis. We
classified beneficiaries as having a hip fracture if one or more
of these diagnosis codes occurred in a hospital inpatient claim
or if it occurred in an outpatient or physician claim and were
accompanied by an HCPCS code (2723027248) for hip fracture

2326

WRIGHT ET AL.

repair. This algorithm has been shown to be valid, with a positive

predictive value of 93% to 98%.(17,18)

Statistical analysis
For each race/ethnic group, we used the total number of personyears and incident hip fractures to calculate the crude hip
fracture incidence rate per 100,000 person-years by gender for
2-year periods. Two-year instead of annual incidence rates were
calculated based on the small number of fractures observed in
men. We standardized all rates to the age distribution of the
US population (men and women combined)
65 years of age
using the 2010 US Census data.(19) We calculated the percent
difference between the 2000 and 2009 age-standardized rates
for each race/ethnic group and used linear regression to test
for significant trends in the rates. Trends in the age-specific
incidence rates were compared for those older and younger than
75 years by race/ethnicity.
For a sensitivity analysis, we calculated hip fracture incidence
rates for the years 2006 to 2009 using an alternative race/
ethnicity variable available in Medicare data. This variable utilizes
an algorithm, created by Eicheldinger and Bonito(16) that aimed
to reclassify beneficiaries based on surname and language
preference. This algorithm was aimed to improve identification
of Asian and Hispanic beneficiaries in Medicare data. Sensitivity
increased from 29.5% using self-report alone, to 76.6% using the
algorithm among Hispanic beneficiaries, and increased from
54.7% to 79.2% among Asian beneficiaries.(16) The surnamebased variable is only available from 2006 and on; thus, we only
compared the incidence rates between the two race/ethnicity
variables, and did not examine trends. All analyses were
conducted using SAS version 9.2 (SAS Institute, Inc., Cary, NC,
USA).

Results
On average, 821,475 women and 632,162 men met the study
eligibility criteria in each 2-year period. Approximately 88.3% of
the cohort in each period was white, 7.9% black, 1.4% Asian, 1.6%
Hispanic, and 0.7% of other racial/ethnic background. Between
2000/2001 and 2008/2009, the proportion of Asian beneficiaries
increased by 39% in men and 66% in women, and the proportion
of Hispanic beneficiaries increased by 7% among men and 22%
among women. Overall, the racial/ethnic distribution of the
study population was comparable to Medicare as a whole;
however, those excluded because they were enrolled in
Medicare Advantage plans throughout the 10 years of the
study had a larger proportion of Asian (2.0%) and Hispanic (2.5%)
and a smaller proportion of black (7.0%) beneficiaries.
Over the 10 years, 81,247 hip fractures occurred in women and
27,828 in men. The majority of fractures were identified using
inpatient claims, but 3.2% of hip fractures in women and 3.5% of
the fractures in men were identified using diagnoses from
outpatient claims paired with hip fracture repair codes. The
proportion of hip fractures identified by outpatient claims did
not differ significantly by race/ethnicity.
The numbers of hip fractures decreased between 2000/2001
and 2008/2009 by 15% among white and 21% among black
Journal of Bone and Mineral Research

women, while the numbers increased for both Asian (26%) and
Hispanic (21%) women (Table 1). Age-adjusted hip fracture rates
decreased over the 10 years among both white and black
women. The decreasing trend in white women was consistent
over the time period (Fig. 1) and was significant (p for trend
0.046) with an average decrease of approximately 11.7 per
100,000 person years over the 10 years (Table 1). The decrease in
the age-standardized rate was approximately 10.7 per 100,000
person-years in black women and 11.4 per 100,000 person-years
among Asian women. The rates of Hispanic women changed
minimally during 2000/2001 to 2008/2009.
Between 2000/2001 and 2008/2009, the numbers of hip
fractures decreased by 3% for white and 10% for black men,
whereas the numbers increased among both Asian (38%) and
Hispanic (20%) men (Table 2). Age-standardized hip fracture
rates displayed a statistically significant decreasing trend in
white men and statistically nonsignificant decreasing trends in
black and Asian men (Table 2, Fig. 2). Overall, the incidence rate
among Hispanic men increased by 2.8 per 100,000 person years,
but this increase was not statistically significant.
Analysis of hip fracture rates by calendar time and age group
indicated that among those 65 to 74 years of age, rates of hip
fracture were relatively low, changes over time were relatively
small, and trends were not statistically significant (Table 3). In this
age group, point estimates of the average change in rates

Fig. 1. Age-standardized hip fracture incidence in women from 2000 to

2009 by race/ethnicity.

suggested that white and Asian women and men and Hispanic
women experienced decreases, while black women and men
and Hispanic men had increases. Among those
75 years of age,
substantial decreases in rates occurred for white women
(average change, 24.5 fractures per 100,000 person-years;

Table 1. Change in Hip Fracture Rates Among Women by Race/Ethnicity Between 2000 and 2009
White

Black
Rate

2000-2001
2002-2003
2004-2005
2006-2007
2008-2009

Ratea

Hip Fx cases (n)

Crude

Adjusted

Hip Fx cases (n)

Crude

Adjusted

16,296
15,867
15,690
15,095
13,905

1235.2
1156.7
1131.1
1136.1
1088.7

1084.6
1014.8
998.6
1001.7
975.2

624
629
599
506
492

514.0
488.1
452.7
411.8
424.3

485.6
463.9
432.6
397.3
411.7

Average changeb

95% CI

Average changeb

95% CI

11.6

(22.8, 0.4)

0.046

10.7

(18.5, 2.9)

0.22

Asian

Hispanic
Ratea

2000-2001
2002-2003
2004-2005
2006-2007
2008-2009

Ratea

Hip Fx cases (n)

Crude

Adjusted

Hip Fx cases (n)

Crude

Adjusted

108
105
133
142
136

661.1
552.8
608.5
611.3
543.2

624.2
512.3
547.2
543.8
494.4

166
173
187
193
201

773.9
753.2
759.0
798.2
828.2

720.8
643.1
621.3
645.0
691.2

Average changeb

95% CI

Average changeb

95% CI

11.4

(31.3, 8.5)

0.17

2.9

(25.8, 20.1)

0.72

CI confidence interval; Fx fracture.

a
Rates per 100,000 person-years.
b
Average change in age-standardized incidence per 100,00 person years from 2000/2001 to 2008/1009 using linear regression trend test.

Journal of Bone and Mineral Research

RECENT TRENDS IN HIP FRACTURE RATES BY RACE/ETHNICITY AMONG OLDER US ADULTS

2327

Table 2. Change in Hip Fracture Rates Among Men by Race/Ethnicity Between 2000 and 2009
White

Black
Ratea

2000-2001
2002-2003
2004-2005
2006-2007
2008-2009

Ratea

Hip Fx cases (n)

Crude

Adjusted

Hip Fx cases (n)

Crude

Adjusted

5069
5251
5433
5294
4949

562.6
545.8
548.3
549.4
524.9

560.8
544.9
546.1
543.8
525.7

264
258
249
260
238

374.4
334.9
311.8
342.1
322.5

400.7
364.0
341.3
372.9
353.3

Average changeb

95% CI

Average changeb

95% CI

3.6

(6.6, 0.5)

0.04

4.3

(14.7, 6.1)

0.28

Asian

Hispanic
Ratea

Ratea

Hip Fx cases (n)

Crude

Adjusted

Hip Fx cases (n)

Crude

Adjusted

34
42
34
32
47

288.6
308.1
220.9
197.6
272.6

277.6
295.5
207.8
185.1
262.0

66
70
81
78
79

415.5
404.9
447.4
450.9
463.3

418.8
379.0
396.2
421.9
424.9

Average changeb

95% CI

Average changeb

95% CI

7.1

(31.2, 17.0)

0.42

2.8

(7.6, 13.1)

0.46

2000-2001
2002-2003
2004-2005
2006-2007
2008-2009

Adj. rate age-standardized rate to the 65 US populations based on the 2010 Census; CI confidence interval; Fx fracture.
a
Rate per 100,000 person-years.
b
Average change in age-standardized incidence per 100,00 person years from 2000/2001 to 2008/1009 using linear regression trend test.

p < 0.001) and men (13.3, p < 0.048), black women (23.8,
p < 0.001) and men (20.7, p 0.07), and Asian women
(21.6, p 0.22) and men (31.8, p 0.27), but not for Hispanic
women (3.0, p 0.80) or men (5.7, p 0.84).
In the sample with the surname-based race/ethnicity variable
(82% of the total population), the number of Hispanic

beneficiaries increased by 173% in women and 185% in men;

the number of hip fractures also increased by similar proportions
(130% in women and men). Similarly, the number of Asian
beneficiaries increased by 30% in women and 37% in men, which
resulted in a 30% increase in the number of hip fracture in
women and 37% in men. The number of white beneficiaries and
hip fracture cases decreased, and no changes were observed
among black beneficiaries in either the population or hip fracture
case size. The increase in size of both the population and hip
fracture cases did not dramatically alter the age-standardized
rates between the self-reported and the surname-based race/
ethnicity variable among women and Hispanic men (Table 4).
Large differences were seen between the two race/ethnicity
variables among Asian men from 2006 to 2007, potentially due to
the large relative change in a small number of hip fracture cases.

Discussion

Fig. 2. Age-standardized hip fracture incidence in men from 2000 to

2009 by race/ethnicity.

2328

WRIGHT ET AL.

Similar to the US trends reported by Brauer and colleagues(4)

from 1995 to 2005, we found that overall, hip fracture incidence
decreased by 8% in men and by 14% women between 2000 and
2009 and that the downward trend persisted through 2009
among older US adults. However, our results indicate that trends
varied by race/ethnicity and age. We observed modest decreases
Journal of Bone and Mineral Research

Table 3. Annual Change in Hip Fracture Incidence by Age Group from 2000 to 2009
Women

<75 years old

White
Black
Asian
Hispanic

75 years old
White
Black
Asian
Hispanic

Men

Average
rate

Average
changea

95% CI

Average
rate

Average
changea

340.2
157.6
178.2
239.9

2.4
0.4
6.7
5.3

(5.8, 1.1)
(4.9, 5.8)
(19.4, 6.1)
(12.7, 2.0)

0.15
0.85
0.26
0.13

192.6
187.2
109.2
187.0

3.3
1.7
1.8
12.6

(7.5,
(17.5,
(51.1,
(53.1,

0.9)
20.8)
47.4)
78.2)

0.09
0.80
0.91
0.59

1839.1
770.0
991.9
1176.3

24.5
23.8
21.6
3.0

(34.0, 15.0)
(33.4, 14.3)
(59.0, 15.7)
(29.3, 23.4)

<0.001
<0.001
0.22
0.80

961.9
576.7
411.7
671.8

13.3
20.7
31.8
5.7

(26.4, 0.2)
(44.2, 2.7)
(107.1, 43.4)
(90.2, 78.8)

0.048
0.07
0.27
0.84

95% CI

CI confidence interval.
a
Annual change in age-standardized incidence per 100,000 person years from linear regression trend test.

in hip fracture incidence for white, black, and Asian Medicare

beneficiaries, although results in white beneficiaries reached
statistical significance. The declines in incidence rates among
whites, blacks, and Asians were driven primarily by declines
among older individuals. We found little evidence of any change
in hip fracture incidence rates among Hispanics.
To our knowledge, there has not been a recent large scale
evaluation of hip fracture incidence by race/ethnicity in the
United States. Baron and colleagues(14) examined hip fracture
incidence rates from 1986 to 1989 in the Medicare 5% sample of
white and black beneficiaries, but data on other racial/ethnic
minorities were not available, and the investigators did not
provide information on secular trends. The two most recent

Table 4. Comparing Age-Standardized Hip Fracture Incidence

Rate Among Asian and Hispanic Beneficiaries by Race/Ethnicity
Variable
Hip fracture cases
SR
Women
Asian
2006-2007
2008-2009
Hispanic
2006-2007
2008-2009
Men
Asian
2006-2007
2008-2009
Hispanic
2006-2007
2008-2009

%
RTI Difference

Adjusted rate
SR

RTI

%
Difference

141 179
136 177

27.0
30.1

588.4 601.8
508.0 534.5

2.3
5.2

190 436
201 458

129.5
127.9

664.0 676.3
677.1 686.6

1.9
1.4

32
47

49
62

53.1
31.9

196.6 236.3
273.5 281.5

20.2
2.9

76 177
79 181

132.9
129.1

459.7 435.6
448.5 428.6

5.2
4.5

SR Self-reported race/ethnicity; RTI surname based race/ethnicity.

Journal of Bone and Mineral Research

studies we identified examined hip fracture rates longitudinally

by race and ethnicity, and they were conducted in the statewide
hospital discharge databases of New York(12) and California.(13)
Decreasing hip fractures rates were observed among white
women and men of New York, California, and nationwide, as
indicated in the current study. Zingmond and colleagues(13)
found a statistically significant increase in the hip fracture
incidence among Hispanics, whereas our study found no change
in rates over the 10 years.
Outside of the differences in the years being examined in each
study, the racial/ethnic distribution of the states of New York and
California and the country as a whole may be a large explanation
in the differences between the two previous studies and ours.
Although our study is nationally representative and it included
relatively large numbers of nonwhite individuals, the racial/
ethnic distribution of the California population during the latest
6 years of observation (19952000) was approximately 84%
white, 3% black, 4% Asian, and 8% Hispanic,(13) which differed
significantly from the 8% black and approximately 1.5% Asian
and Hispanic in our study. Similarly, the New Yorkbased
study(12) had a larger proportion of Asian and Hispanic hip
fracture cases than ours.
Comparison of the rates found in our Medicare study to that of
Fang and colleagues(12) and Zingmond and colleagues(13) was
slightly hindered for a number of reasons. First, the results in
Fang and colleagues(12) and Zingmond and colleagues(13) were
not presented in a manner that would allow us to apply our rates
to their population or vice versa. In an attempt to make the
studies more comparable, we calculated age-standardized hip
fracture incidence rates using the 2000 US Census data in
addition to the 2010 data. Although incidence rate point
estimates changed slightly, the overall trends did not change.
Secondly, the previous studies were not restricted to a Medicareeligible population and only included hospitalized hip fractures,
whereas we were able to include hip fractures identified in both
inpatient and outpatient claims.
Explanations for the decreasing trends of hip fracture
incidence offered in prior studies include: increasing use of

RECENT TRENDS IN HIP FRACTURE RATES BY RACE/ETHNICITY AMONG OLDER US ADULTS

2329

antiosteoporosis therapies, increasing emphasis on nutritional

factors such as calcium and vitamin D, and lifestyle factors such
as physical activity.(4,13) The largest declines in hip and other
osteoporotic fracture rates worldwide reported in previous
studies corresponded to the launch and widespread use of the
primary antiosteoporosis medications, the bisphosphonates.(4,5)
However, studies examining the utilization of these medications,
by gender and race/ethnicity are limited,(20) and to our
knowledge, there are no longitudinal studies on trends in use
of antiresorptives by gender or race/ethnicity in the literature.
In recent years, there has been more of an emphasis on the
interplay between bone and body composition.(2123) Several
molecular and cellular theories, from the shared origin of bone
formation and fat cells to reduction in hormone and growth
factors needed to differentiate these cells, suggest that increases
in body mass due to accumulation of fat mass does not equal an
increase in bone strength, the main determinant of fracture
risk.(21) Between 1999/2000 and 2007/2008, Flegal and colleagues(24) reported an 11%, 44%, and 21% increase in obesity
(body mass index >30 kg/m2) among non-Hispanic white, nonHispanic black, and Mexican American men, respectively, and a
17% increase among Mexican American women
60 years old
participating in the National Health and Nutrition Examination
Study. Although only significant in black men, one can
hypothesize that the increase in the obesity rates may be a
contributing factor in the lack of change in hip fractures rates
observed among some of the minority populations, particularly
with the recent evidence that risk for certain fractures increases
among obese people compared to normal weight individuals
with and without adjusting for bone mineral density.(2528) Other
factors such as falls, measures of bone strength, or other
comorbidities and medications could potentially explain the
observed trends. However, there is little to no recent literature on
racial/ethnic difference, particularly longitudinal studies, of these
factors and hip fracture incidence.
To our knowledge, our study is the largest recent examination
of hip fracture incidence by race/ethnicity in the United States to
date; however, it is not without limitations. The first relates to the
exclusion of beneficiaries enrolled in Medicare Advantage plans
due to a lack of complete claims for health services. In 2009, 22%
of Medicare beneficiaries were enrolled in Medicare Advantage
plans.(29) Enrollment in these plans varies significantly by region
of the country, and this may have had a significant effect on
the sample size of certain race/ethnic groups that are more
predominant in areas with high HMO access. A larger proportion
of Asian (2.0% versus 1.4%) and Hispanic (2.5% versus 1.6%)
beneficiaries were continuously enrolled in Medicare Advantage
plans than those included in our analyses, thus making results of
the study primarily generalizable to the traditional fee-forservices Medicare population.
The proportion of Asian and Hispanic beneficiaries of our
sample was lower than the proportion of people
65 years old
reporting to be Asian alone (3.4%) and having Hispanic origin
(7%) in the 2010 US Census,(30) suggesting the possibility of
misclassification in race/ethnicity. Studies using the Medicare
Current Beneficiary Survey (MCBS) have shown discrepancies
between MCBS race/ethnicity, typically used as the goldstandard, and what is recorded in the Medicare claims

2330

WRIGHT ET AL.

data.(31,32) The reported discrepancies were more prominent

among American Indians/Alaskan Natives, Hispanic Americans,
and Asian Americans.(31,32) A recent study in both Medicare
Advantage and the fee-for-service population showed low
sensitivity of the race/ethnicity variable in the Medicare
administrative data to the self-report in the Medicare Consumer
Assessments of Healthcare Providers and Systems Survey.(33)
Misclassification could potentially underestimate the number of
fractures observed, particularly among Asian and Hispanic
beneficiaries, which would bias estimates of the true burden of
hip fracture in the population. Our sensitivity analysis using the
surname-based algorithm created by Eicheldinger and Bonito(16)
allowed us to examine this misclassification. Although the
population increased over 170% in Hispanic beneficiaries and
over 30% in Asian beneficiaries, our sensitivity analyses showed
little relative differences between the incidence rates using
self-reported variable available in the claims data and the
recalculated race/ethnicity variable among Asian women and
Hispanic women and men. Future studies with more recent data
will allow for a more thorough comparison of hip fracture trends
observed using the self-reported race/ethnicity versus the
corrected race/ethnicity.
In summary, we found that from 2000 to 2009, hip fractures
have significantly declined among white men and women.
Declines were most prominent in beneficiaries 75 years and
older among white, black, and Asian beneficiaries of both
genders. Unlike the other racial/ethnic groups, no significant
change in hip fracture incidence was observed among Hispanic
beneficiaries. Our results represent an average of the country as a
whole, and we fully acknowledge that the racial/ethnic specific
trends present may not be similar in regions of the country that
do not have the average proportions of each racial/ethnic group.
Even if similar proportions are observed, the ancestral origins of
the population may also factor into overall bone strength and
fracture rates.

Conclusion
Unlike the nation as a whole, hip fracture incidence rates have
not declined in all racial/ethnic and age groups. The proportion
of Americans 65 years of age or older is projected to increase
80% from 2010 to 2030.(34) The Hispanic population represents
the largest growing minority population in the United States, and
according to projections, the proportion of the US Hispanic
population
65 years old will increase by 200% compared to
only 60% among non-Hispanic whites.(35,36) Without a change in
the current hip fracture incidence, the total number of hip
fractures, on average, would increase by similar proportions in
each group. More targeted hip fracture prevention efforts are
needed to minimize the potential negative effects of an
increasing number of hip fractures with the aging population,
particularly among Hispanics, on the nations health.

Disclosures
All investigators receive research support from Amgen.
Additional financial disclosures include: JRC: Research grant:
Journal of Bone and Mineral Research

Eli Lilly, Merck, Novartis, Proctor & Gamble, Roche; Consulting

fees: Merck, Amgen, Eli Lilly, Roche, Novartis. KGS: Research
grant: Eli Lilly, Novartis, Merck; Consulting fees: Eli Lilly, Novartis,
Merck, Amgen.

Acknowledgments
This research was supported by a contract between UAB and
Amgen, Inc. Only the authors had access to the data. The analysis,
presentation and interpretation of the results were solely the
responsibility of the authors.
Authors roles: Study design: NCW, JRC, ESD, and KGS. Data
acquisition, JRC, ESD, MLK, MAM, and KGS. Data analysis: NCW
and WKS. Data interpretation: NCW, JRC, ESD, MLK, MAM, KGS,
WKS, HY, and JZ. Manuscript drafting: NCW. Manuscript revision:
NCW, JRC, ESD, MLK, MAM, KGS, WKS, HY, and JZ. NCW had full
access to all of the data in the study and takes responsibility for
the integrity of the data and accuracy of the analyses.

13. Zingmond DS, Melton LJ 3rd, Silverman SL. Increasing hip fracture
incidence in California Hispanics, 1983 to 2000. Osteoporos Int. 2004
Aug; 15(8):60310.
14. Baron JA, Barrett J, Malenka D, Fisher E, Kniffin W, Bubolz T, Tosteson
T. Racial differences in fracture risk. Epidemiology. 1994 Jan; 5(1):
427.
15. Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E. Kanis JA;
Manitoba Bone Density Program. A comparative study of using
non-hip bone density inputs with FRAX1. Osteoporos Int. 2012
Mar; 23(3):85360.
16. Eicheldinger C, Bonito A. More accurate racial and ethnic codes for
Medicare administrative data. Health Care Financ Rev. 2008; Spring;
29(3):2742.
17. Jean S, Candas B, Belzile E, Morin S, Bessette L, Dodin S, Brown JP.
Algorithms can be used to identify fragility fracture cases in physician-claims databases. Osteoporos Int. 2012 Feb; 23(2):483501.
18. Ray WA, Griffin MR, Fought RL, Adams ML. Identification of fractures
from computerized Medicare files. J Clin Epidemiol. 1992 Jul; 45(7):
70314.
19. U.S. Census Bureau. Population by Age and Sex: 2010 Census
Summary File 1 [Internet]. Washington (DC): U.S. Census Bureau;
2010 [cited 14 June 2012]. Available from: http://www.census.gov/
prod/cen2010/doc/sf1.pdf.
20. Farley JF, Cline RR, Gupta K. Racial variations in antiresorptive
medication use: results from the 2000 Medical Expenditure Panel
Survey (MEPS). Osteoporos Int. 2006;17(3):395404.

References
1. Cheng H, Gary LC, Curtis JR, Saag KG, Kilgore ML, Morrisey MA,
Matthews R, Smith W, Yun H, Delzell E. Estimated prevalence and
patterns of presumed osteoporosis among older Americans based on
Medicare data. Osteoporos Int. 2009 Sep; 20(9):150715.
2. Holroyd C, Cooper C, Dennison E. Epidemiology of osteoporosis. Best
Pract Res Clin Endocrinol Metab. 2008 Oct; 22(5):67185.
3. Cooper C, Cole ZA, Holroyd CR, Earl SC, Harvey NC, Dennison EM,
Melton LJ, Cummings SR, Kanis JA. Secular trends in the incidence of
hip and other osteoporotic fractures. Osteoporos Int. 2011 May;
22(5):127788.
4. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and
mortality of hip fractures in the United States. JAMA. 2009 Oct 14;
302(14):15739.
5. Leslie WD, ODonnell S, Jean S, Lagace C, Walsh P, Bancej C, Morin S,
Hanley DA, Papaioannou A. Trends in hip fracture rates in Canada.
JAMA. 2009 Aug 26; 302(8):8839.

21. Duque G. Bone and fat connection in aging bone. Curr Opin
Rheumatol. 2008 Jul; 20(4):42934.
22. Reid IR. Relationships between fat and bone. Osteoporos Int. 2008
May; 19(5):595606.
23. Rosen CJ, Bouxsein ML. Mechanisms of disease: is osteoporosis the
obesity of bone?. Nat Clin Pract Rheumatol. 2006 Jan; 2(1):3543.
24. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends
in obesity among US adults, 1999-2008. JAMA. 2010 Jan 20; 303(3):
23541.
25. Nielson CM, Marshall LM, Adams AL, LeBlanc ES, Cawthon PM, Ensrud
K, Stefanick ML, Barrett-Connor E, Orwoll ES. BMI and fracture risk in
older men: the osteoporotic fractures in men study (MrOS). J Bone
Miner Res. 2011 Mar; 26(3):496502.

6. Cauley JA. Defining ethnic and racial differences in osteoporosis and

fragility fractures. Clin Orthop Relat Res. 2011 Jul; 469(7):18919.

26. De Laet C, Kanis JA, Oden A, Johanson H, Johnell O, Delmas P, Eisman

JA, Kroger H, Fujiwara S, Garnero P, McCloskey EV, Mellstrom D,
Melton LJ 3rd, Meunier PJ, Pols HA, Reeve J, Silman A, Tenenhouse A.
Body mass index as a predictor of fracture risk: a meta-analysis.
Osteoporos Int. 2005 Nov; 16(11):13308.

7. Megyesi MS, Hunt LM, Brody H. A critical review of racial/ethnic

variables in osteoporosis and bone density research. Osteoporos Int.
2011 Jun; 22(6):166979.

27. Gnudi S, Sitta E, Lisi L. Relationship of body mass index with main
limb fragility fractures in postmenopausal women. J Bone Miner
Metab. 2009;27(4):47984.

8. Jacobsen SJ, Goldberg J, Miles TP, Brody JA, Stiers W, Rimm AA. Race
and sex differences in mortality following fracture of the hip. Am J
Public Health. 1992 Aug; 82(8):114750.

28. Compston JE, Watts NB, Chapurlat R, Cooper C, Boonen S, Greenspan

S, Pfeilschifter J, Silverman S, Diez-Perez A, Lindsay R, Saag KG,
Netelenbos JC, Gehlbach S, Hooven FH, Flahive J, Adachi JD, Rossini
M, Lacroix AZ, Roux C, Sambrook PN, Siris ES. Obesity is not protective
against fracture in postmenopausal women: GLOW. Am J Med. 2011
Nov; 124(11):104350.

9. Penrod JD, Litke A, Hawkes WG, Magaziner J, Doucette JT, Koval KJ,
Silberzweig SB, Egol KA, Siu AL. The association of race, gender, and
comorbidity with mortality and function after hip fracture. J Gerontol
A Biol Sci Med Sci. 2008 Aug; 63(8):86772.
10. Graham JE, Chang PF, Berges IM, Granger CV, Ottenbacher KJ. Race/
ethnicity and outcomes following inpatient rehabilitation for hip
fracture. J Gerontol A Biol Sci Med Sci. 2008 Aug; 63(8):8606.

29. Henry J. Kaiser Family Foundation. Medicare Advantage Fact Sheet,

April 2009 [Internet]. Menlo Park (CA): The Henry J. Kaiser Family
Foundation; 2009 [cited 14 June 2012]. Available from: http://
www.kff.org/medicare/upload/2052-12.pdf.

11. Nguyen-Oghalai TU, Ottenbacher KJ, Kuo YF, Wu H, Grecula M,

Eschbach K, Goodwin JS. Disparities in utilization of outpatient
rehabilitative care following hip fracture hospitalization with respect
to race and ethnicity. Arch Phys Med Rehabil. 2009 Apr; 90(4):5603.

30. U.S. Census Bureau. Table 10. Resident Population by Race, Hispanic
Origin, and Age: 2000 and 2009 [Internet]. Washington (DC): U.S.
Census Bureau; 2010 [cited 14 June 2012]. Available from: http://
www.census.gov/compendia/statab/2012/tables/12s0010.pdf.

12. Fang J, Freeman R, Jeganathan R, Alderman MH. Variations in hip

fracture hospitalization rates among different race/ethnicity groups
in New York City. Ethn Dis. 2004; Spring; 14(2):2804.

31. Arday SL, Arday DR, Monroe S, Zhang J. HCFAs racial and ethnic data:
current accuracy and recent improvements. Health Care Financ Rev.
2000; Summer; 21(4):10716.

Journal of Bone and Mineral Research

RECENT TRENDS IN HIP FRACTURE RATES BY RACE/ETHNICITY AMONG OLDER US ADULTS

2331

32. Waldo DR. Accuracy and bias of race/ethnicity codes in the Medicare
enrollment database. Health Care Financ Rev. 2004-2005; Winter;
26(2):6172.

June 14, 2012]. Available from: http://www.census.gov/population/

www/projections/summarytables.html.

33. Zaslavsky AM, Ayanian JZ, Zaborski LB. The validity of race and
ethnicity in enrollment data for Medicare beneficiaries. Health
Serv Res. 2012 Jun; 47(3 Pt 2):130021.

35. Ensrud KE, Lui LY, Taylor BC, Schousboe JT, Donaldson MG, Fink HA,
Cauley JA, Hillier TA, Browner WS, Cummings SR. A comparison of
prediction models for fractures in older women: is more better?. Arch
Intern Med. 2009 Dec 14; 169(22):208794.

34. U.S. Census Bureau. Table 2. Projections of the Population by

Selected Age Groups and Sex for the United States: 2010 to 2050
(NP2008-T2) [Internet]. Washington (DC): Population Divisions,
U.S. Census Bureau; 2008 [updated August 14, 2008; cited 2012

36. Donaldson MG, Palermo L, Schousboe JT, Ensrud KE, Hochberg

MC, Cummings SR. FRAX and risk of vertebral fractures: the
fracture intervention trial. J Bone Miner Res. 2009 Nov; 24(11):
17939.

2332

WRIGHT ET AL.

Journal of Bone and Mineral Research